• HPI

    • 40-year-old male with no significant past medical history, brought to ER after falling from a zipline
    • Patient fell approximately 40 feet, with immediate onset bilateral hand numbness and weakness
    • A C-spine fracture was identified at an outside hospital, HCT negative and trauma evaluation otherwise negative
    • Patient arrives 6 hours after his initial injury
    • PMH – negative
    • PSurgHx – negative
    • Meds – none
    • All – NKDA
    • SocHx – professional skydiver, current heavy smoker

    Exam

    • Neurologically AAO x 3
    • Cranial nerves intact
    • 0/5 intrinsics, 0/5 grip, 3/5 wrist extension/flexion, 5/5 bicep, tricep and shoulder function
    • Diffuse numbness in distal upper extremities
    • Full strength bilateral lower extremities
    • Mean Arterial pressure 65

    Figure 1

    Figure 2

    1. First line agent for blood pressure maintenance includes:

    2. Should this patient receive steroids:

    3. Optimal Management includes:

    4. Management of this patient should include:

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:
     
    • Steroids only if started within 3 hours of injury as per post-hoc analysis results of NASCIS III study.
    • Unstable distraction trauma. Requires 360 degrees instrumentation. Anterior first, possibly w/ corpectomy followed by lateral mass fusion spanning the injured levels
    • We might consider giving the patient heparine 12 hours after surgery to reduce the ischimec insult
    • Thank you for good questions.
    • Elective surgery for me would be as soon as stabilized and the next appropriate OR time available with 24 hours. That would be my choice in case he is neurologically stable.
      In case of progressive neurological worsening, requires acute decompression anteriorly via corpectomy
    • This patient had severe cervical spine injury with c5-c6 disc prolapse, first he needs anterior discectomy plus fusion,post op cervical collar for atleast 2 weeks,for # of spinous process and lamina,if not benificial then post decomprrssion and fusion.
    • We might consider giving the patient heparine 12 hours after surgery to reduce the ischimec insult
    • Answer need to be more  detailed this is best approached posterior and if resistance is met during reduction then the anterior approach with removal of HNP should be performed just as 89 this was a case of pure facet jump

    • Clinically central cord syndrome. Radio logically significant anterior compression with possible  instability due to lamina fracture C6.

    • In this case above it is needed special attemption because sometime for us in developing country,we have failed in management of it,mainly in fall, accident ,people dont pay attemption in neck protection. At initial management sometime we dont have drug as corticosteroid to avoid some complication.
    • This can be treated in a variety of ways. Impossible to say only one method is correct. Conservative management with rigid externalization could be adequate, but risk of delayed vertebral artery injury possible, also late instability. Anterior approaches could be reinforced with external immobilization for a period of six weeks to three months as well, with corpectomy. Do not believe a single answer fits all
    • Cannot tell if disc combined with hematoma in ventral epidural space. Would plan for 2 level (C5-6, C6-7) ACDF with conversion to C6 corpectomy/fusion if seemed could not adequately decompress canal.
    • Since the patient has a central cord syndrome and the images correspond to anterior and posterior compression.First medical treatment and after to avoid unestability I would do an anterior-posterior decompression procedure with fusion.
    • Anterior C6 median corpectomy, C5-7 anterior column support with Ulrich VBR, morselizelized autograft and Osiris Therapeutics Ovation mesenchymal stem cell tissue repair suspension

      Posterior lateral mass screws C4-C7 and pedicle screws T1/ rods with cross links @ C5 & C6; lateral mass fusion with morselized autograft from resected lamina and fractured spinous processes

      Aspen Vista cervical orthosis with thoracic
      extension

      Check vitamin D, testosterone, and thyroid hormone levels

      Enter pt in smoking cessation program

      Postop Orthofix external bone growth stimulator

    • Neurologic deficit consistent with central cord syndrome.
      MRI demonstrates cord compression from a ventral HNP which extends from the C5-6 disc space to just below C6-7 disc space and displaces the cord posteriorly. Circuferential CDF signal is obliterated. High signal is present in the cord just below the caudal most portion of the HNP. Dorsal compression is noted from the ligamentum flavum.

      Posterior ligamentous complex is disrupted with the spinous process and lamina fractures seen on CT.

      Anterior C6 median corpectomy, C5-7 anterior column support with Ulrich VBR, morselizelized autograft and Osiris Therapeutics Ovation mesenchymal stem cell tissue repair suspension.

      Anterior constrained plate / screw construct from C5-C7

      Posterior lateral mass screws C4-C7 and pedicle screws T1/ rods with cross links @ C5 & C6; lateral mass fusion with morselized autograft from resected lamina and fractured spinous processes

      Aspen Vista cervical orthosis with thoracic
      extension

      Check vitamin D, testosterone, and thyroid hormone levels

      Enter pt in smoking cessation program

      Postop Orthofix external bone growth stimulator

    • Definite C6 corpectomy, epidural evac, C5-7 fusion.  Then posterior fusion.  Classic front-back. 

    • I would like to 360 degree decompression and fusion for 2 reasons, a)it will compensate for post traumatic edema, hence both anterior and posterior decompression. b) since all the three columns are disturbed 360 degree fusion is required.

    • The patient ha sano therecipeproject surgycal options for example corpectomy and fusión, fixation

    • Acute decompression and fusion is needed   as long as the patient is hemodynamically stable.  Because of multiple injuries, anterior and posterior decompression and fusion seems a better option. Whether the early surgery will lead to recovery remains to be seen

    • Two level discectomy and fusion with acure rehab initiated. OK to place in a collar and I would do this early.

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    Pubmed References

    • Neurosurgery. 2013 Aug;60 Suppl 1:82-91. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, Harrigan MR, Rozelle CJ, Ryken TC, Theodore N.
    • Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S228-34. Classification and surgical decision making in acute subaxial cervical spine trauma. Patel AA, Hurlbert RJ, Bono CM, Bessey JT, Yang N, Vaccaro AR.

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